You are here: Home / Archives for Legal Medicine

Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

1 + 1 = 3 Sometimes – Pharmacology Fun

Mon, 23 Dec 2013 17:00:41 -0500 by
 

Does 1 + 1 always equal 3?

No.

If you do not give all of the medication in a syringe, vial, ampule, you are rounding off. This is where significant figures matter.[1]

1+1 does equal 3 for sufficiently high values of 1.

For those who do not understand this –

Consider a morphine syringe with a volume of 1 ml that contains a total dose of 10 mg.

We intend to give 1 mg.

Can we give exactly 1 mg?

I cannot.

We give an approximation of 1 mg.

What is considered to be 1 mg?
 


 

0.50001 mg should be rounded to 1 mg if we are not using decimal places. We probably do not have the precision to measure that accurately. If we did, we should use all of the significant digits in our documentation.

I am using this as an example to point out that with no decimal places 0.50001 mg is 1 mg.

We round off to the nearest significant digit.

If we are not using decimals, then 1.49999 mg is also 1 mg.

We will not be measuring that as carefully, either.

What we will be doing is trying to get close to 1 mg, but that could be 1.4 mg, or 1.3 mg, or 1.2 mg, or 1.1 mg, 0.9 mg, or 0.8 mg, or 0.7 mg, or 0.6 mg, or 0.5 mg.

How precisely can we measure the amount?

If we tend to underestimate the doses we are giving, we could be giving a couple of doses of 1.3 mg.

1.3 + 1.3 = 2.6, which is rounded to 3.

1 + 1 = 3.

If I gave 1.3 mg and 1.3 mg to the same patient, I gave 1 mg + 1 mg and the

1.4 can be rounded off to 1.

If there are no significant digits beyond the 1, then the value of 1 is anywhere from 0.6 to 1.4.

Add a couple of 1s that add up to 2.5, or greater, and you have 3.

1.2 + 1.3 = 2.5, which is rounded to 3.

When rounded to one significant digit, 1.2 = 1, 1.3 = 1, 1.4 = 1, and 2.5 = 3.

That is not what we generally think of when we think of 1 + 1 = 3.

We assume a precision that may not be there.
 


 

Error bars do not always result in excess.

We can end up with a small number due to wide error bars.

1+1 can equal 1 for sufficiently low values of 1.
 


 

So,

      how

            accurate

                  are

                        we?

–

Footnotes:

–

[1] Significant figures
Wikipedia
Article

.

Filed Under: Critical Judgment, Heresy, Legal Medicine, Math, Pharmacology

Mentally Ill Patient Escapes EMS and Sues for Injuries

Fri, 09 Aug 2013 14:00:03 -0400 by
 

A Bronx woman is suing police and emergency medical services providers for injuries that occurred when she escaped custody and ended up leaping from a third story window.[1]

 

What is our liability for the behavior of patients with behavioral problems?

What is our authority to control the behavior of patients with behavioral problems?

 

She has filed suit against the city, the ambulance service, and the police officers for not properly supervising and restraining her. She argues that she was clearly mentally ill and should have been immobilized for her own protection.[2]

 

While the police and EMS probably could not have predicted that she would jump from the third floor of the building if she escaped, that does make a pretty good case for her being off her rocker not being responsible for her actions. On the other hand, the LD50 for jumping from a building is 4 floors, so she did not jump from high enough to expect to die.
 

It’s unclear whether the officers called for an ambulance because Rodriguez suffered injuries from damaging the car or because they recognized that she might be mentally ill.[2]

 

We, and the police, are called to protect everyone else from patient like this, but we are also called to protect the patients from themselves.

Kelly Grayson just posted on Facebook about the difference between a couple of behavioral problem patients.
 

What’s more stressful than dealing with the violent, hulking behemoth with a tenuous cheese-cracker interface?

Dealing with the *potentially* violent, hulking behemoth with a tenuous cheese-cracker interface, that’s what.[3]

 


Image credit.
 

If they all looked like this, it would be easy to treat aggressively and avoid problems, but that is not the way many will present – especially after being restrained by police.

The article does not provide many details, but that is the essence of the problem Kelly is describing – these patients are unpredictable unknowns. Many will sit calmly and cooperate at all times. Others are just waiting for the opportunity to do something creative, which is not good for us.

These patients are the known unknowns, but their future behaviors are the unknown unknown.[4] Often, they do not even know what they are going to do.
 

I started out by asking –

What is our liability for the behavior of patients with behavioral problems?

That may be up to a jury. We also have to live with the adverse outcomes we could have prevented.
 

The responders erred in “not restraining or immobilizing [Rodriguez] to ensure that she was not capable of hurting herself” and were negligent in “allowing her to leave the ambulance without fully assessing her mental state,” the complaint states. It cites a line in Article 9 of the New York Mental Hygiene laws, which notes the “Powers of Certain Peace Officers and Police Officers to take into custody any persons who appears to be mentally ill and is conducting himself or herself in a manner which is likely to result in serious harm to the person or others.”[2]

 

Interesting assertions, but we do not have anywhere near enough information to know if they are true. In Pennsylvania, I do not have the authority to involuntarily commit patients.

My preference is to sedate patients. Safer for everyone involved, including the techs, nurses, PAs, and doctors at the hospital.

What is our authority to control the behavior of patients with behavioral problems?

That is often up to the medical director – state, county, service – and the ability of the medical director to understand how unstable these patients can be.
 

I think this is a cautionary tale for all of us. We need to be aware of what our patients are doing once we have them in our care and should not leave them unattended in the back of an ambulance especially when perhaps they are mentally disturbed. I want to make it clear that I’m not second guessing these EMTs.[1]

 

There is a lot to discuss.

–

Footnotes:

–

[1] Mentally Ill Patient Escapes EMS and Sues for Injuries
By podmedic
August 2, 2013
MedicCast
Article

Social Media, EMS and Public Health on Episode 344
By podmedic
July 29, 2013
MedicCast
Article with link to podcast.

–

[2] Woman Sues EMTs, Police for Letting Her Leave Ambulance and Jump Out Apartment Window
By Albert Samaha
Tue., Jul. 16 2013 at 10:30 AM
The Village Voice Blogs
Article

–

[3] What’s more stressful than dealing with the violent, hulking behemoth with a tenuous cheese-cracker interface?
Facebook
Kelly Grayson
Post

–

[4] Secretary Rumsfeld Press Conference at NATO Headquarters, Brussels, Belgium
Secretary of Defense Donald H. Rumsfeld
June 06, 2002
Transcript

Q: Regarding terrorism and weapons of mass destruction, you said something to the effect that the real situation is worse than the facts show. I wonder if you could tell us what is worse than is generally understood.

Rumsfeld: Sure. All of us in this business read intelligence information. And we read it daily and we think about it and it becomes, in our minds, essentially what exists. And that’s wrong. It is not what exists.

Now what is the message there? The message is that there are no “knowns.” There are things we know that we know. There are known unknowns. That is to say there are things that we now know we don’t know. But there are also unknown unknowns. There are things we do not know we don’t know. So when we do the best we can and we pull all this information together, and we then say well that’s basically what we see as the situation, that is really only the known knowns and the known unknowns. And each year, we discover a few more of those unknown unknowns.

It sounds like a riddle. It isn’t a riddle. It is a very serious, important matter.

There’s another way to phrase that and that is that the absence of evidence is not evidence of absence. It is basically saying the same thing in a different way. Simply because you do not have evidence that something exists does not mean that you have evidence that it doesn’t exist. And yet almost always, when we make our threat assessments, when we look at the world, we end up basing it on the first two pieces of that puzzle, rather than all three.

.

Filed Under: Excited Delirium, Heresy, Legal Medicine

Should We Use Immobilization For Penetrating Injuries To The Neck – Comments at Paramedic’s Edge

Thu, 14 Mar 2013 21:30:39 -0400 by
ResearchBlogging.org
 

Are you required to backboard a patient who was shot in the neck no matter how the patient is presenting? [1]

 

That is the entire question that was asked at The Paramedic’s Edge.

There are really several questions being asked.

1. If there is a minor injury, with no neurological deficits, is there any reason to immobilize the patient?

Many responded with variations of – We don’t know where the bullet is, so we must immobilize the patient.

That would make sense – if there were any reason to believe that backboards and/or collars do anything to keep bullets from moving, or if they did anything to protect the spine from bullet injuries.

2. If there are life-threatening injuries to the neck, how will application of a collar help?

3. If the airway is severely compromised, will a collar and board make things better?

4. Why do we think that a simple splint is the correct treatment for a potential injury to a complex series of bones and joints?

I do not know the position of ITLS (International Trauma Life Support Courses), but PHTLS (PreHospital Trauma Life Support) has made their position clear on this.

 

Present prehospital management of penetrating injuries to the head, neck, and torso is based on the premise that the spine is injured until proven otherwise and full immobilization will prevent further propagation of any injury. A review of the trauma literature does not support this practice.[2]

 

What is the policy of PHTLS on immobilization for penetrating injuries?

 

PHTLS Recommendations

  • There are no data to support routine spine immobilization in patients with penetrating trauma to the neck or torso.
  • There are no data to support routine spine immobilization in patients with isolated penetrating trauma to the cranium.
  • Spine immobilization should never be done at the expense of accurate physical examination or identification and correction of life-threatening conditions in patients with penetrating trauma.
  • Spinal immobilization may be performed after penetrating injury when a focal neurologic deficit is noted on physical examination although there is little evidence of benefit even in these cases.[2]

 

This is very interesting.

There are no data to support routine spine immobilization in patients with penetrating trauma to the neck or torso.

What about the absence of data to support routine spine immobilization in patients with penetrating blunt trauma to the neck or torso or anywhere else?

Spine immobilization should never be done at the expense of accurate physical examination or identification and correction of life-threatening conditions in patients with penetrating trauma.

But immobilization is more important than life when it is for blunt trauma?

Spinal immobilization may be performed after penetrating injury when a focal neurologic deficit is noted on physical examination although there is little evidence of benefit even in these cases.

Where is this little evidence of benefit?

The authors spend some time describing the different levels of evidence, but where is the evidence that spinal cord injury due to blunt trauma is prevented, or lessened, with backboards and EMS collars?

Here is the only place the authors appear to give a reference supporting the use of backboards and EMS collars for blunt trauma.
 

Although blunt spinal column injuries will occasionally produce unstable vertebral injuries, which may result in subsequent neurologic propagation if not managed appropriately in the field, this has not been demonstrated to be the case with penetrating trauma.1 [2]

 

Does the referenced paper actually support the use of backboards and EMS collars for blunt trauma?
 

All but two patients had complete injuries at admission. One patient with incomplete injury and another that was neurologically intact had early complete cervical cord injuries after cervical immobilization.[3]

 

The patients got worse after cervical immobilization?
 

Four of the five patients in the early group (mean age 56 years) developed neurologic worsening during application of cervical immobilization less than 24 hours after injury.[3]

 

Neurologic deterioration during the application of cervical immobilization is not evidence that immobilization with backboards and EMS collars improves outcomes.
 

In the other patient with ankylosing spondylitis the injury progressed from C5 to C3 ASIA A CSCI during traction and immobilization. The third patient had an incomplete central cord injury (C4 ASIA D) after a fall. In the emergency department, the patient was extremely agitated and would not remain recumbent while immobilized in a rigid cervical collar. The injury quickly ascended to a C4 complete CSCI with the patient’s selfmanipulation of his neck. The fourth patient was an obese woman with a C8 ASIA A severe central cord injury after a fall whose injury ascended to a C5 ASIA A level after halo vest placement because her body habitus precluded adequate immobilization.[3]

 

The best than can be said about immobilization for blunt trauma based on this paper is –

We need to figure out what we are doing.

The status quo is more of a status FUBAR.

The paper is from a regional spine center, so these are not a bunch of Yahoos.

Back to the original question – Should we be using backboards and EMS collars on patients with penetrating trauma?

No.

The more important question is Should we be using backboards and EMS collars on patients with any trauma?

I don’t see any evidence to justify this intervention.

–

Footnotes:

–

[1] Are you required to backboard a patient who was shot in the neck no matter how the patient is presenting?
The Paramedic’s Edge
Facebook
Article

–

[2] Prehospital spine immobilization for penetrating trauma–review and recommendations from the Prehospital Trauma Life Support Executive Committee.
Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE.
J Trauma. 2011 Sep;71(3):763-9; discussion 769-70. doi: 10.1097/TA.0b013e3182255cb9. Review. No abstract available.
PMID: 21909006 [PubMed – indexed for MEDLINE]

–

[3] The cause of neurologic deterioration after acute cervical spinal cord injury.
Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ.
Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6.
PMID: 11224879 [PubMed – indexed for MEDLINE]

–

Stuke, L., Pons, P., Guy, J., Chapleau, W., Butler, F., & McSwain, N. (2011). Prehospital Spine Immobilization for Penetrating Trauma—Review and Recommendations From the Prehospital Trauma Life Support Executive Committee The Journal of Trauma: Injury, Infection, and Critical Care, 71 (3), 763-770 DOI: 10.1097/TA.0b013e3182255cb9

–

Harrop, J., Sharan, A., Vaccaro, A., & Przybylski, G. (2001). The Cause of Neurologic Deterioration After Acute Cervical Spinal Cord Injury Spine, 26 (4), 340-346 DOI: 10.1097/00007632-200102150-00008

.

Filed Under: Heresy, Legal Medicine, Spinal Immobilization

Did the ‘Tough on Assault of EMS’ Brooklyn DA’s Office Accept a Plea from ADA Michael Jaccarino?

Fri, 15 Feb 2013 08:00:38 -0500 by

 
Did the ‘Tough on Assault of EMS’ Brooklyn DA’s Office Accept a Plea from ADA Michael Jaccarino?

In October, Kings County District Attorney Charles J. Hynes announced his Assaults Against EMT’s and Paramedics Initiative.

In November, Assistant District Attorney Michael Jaccarino (of the Brooklyn DA’s Office) was arrested for assaulting an EMT – including choking the EMT. Choking is not really serious, unless you do not require oxygen to live. I know of some people in EMS who strongly suggest that there is no oxygen getting to their brains, but it would be very wrong for me to test that hypothesis.

 

Kings County District Attorney Charles J. Hynes joined Brooklyn officials including New York Fire Department Commissioner Sal Cassano; Israel Miranda, President of the Uniformed EMT’s, Paramedics and Fire Inspectors Local 2507 FDNY; Senator Martin Golden; Senator Eric Adams; Assemblyman Peter Abbate Jr.; and Assemblyman Felix Ortiz as they called for legislation which would increase penalties for assaults against EMT’s and paramedics. The initiative would also assign an Assistant District Attorney in the Investigations Bureau to review and prosecute these cases.[1]

 

Did the ‘Tough on Assault of EMS’ Brooklyn DA’s Office Accept a Plea from ADA Michael Jaccarino?

Of course they did.

Not just a plea, but no jail time.
 

“That being said,” Jaccarino continued, “I am accepting full responsibility. It’s not going to happen again.”[2]

 

It may be that he does not do this again. Only time will tell.
 

But prosecutors said the misdemeanor disposition was arrived at after a lengthy, detailed investigation — involving interviews with police witnesses, the victim’s partner, the victim herself, and bartenders who had served Jaccarino that night.[2]

 

I understand.

It has been my experience that spending a lot of time interviewing bartenders leads to poor decisions – and I am not even a lawyer.
 

“He is paying the price. He is no longer going to be an assistant district attorney, I can assure everyone in this courtroom of that,” Jaccarino’s lawyer, Gary Farrell, said.[2]

 

Is he going to still be a lawyer?

Private practice is where the money is in law.

Is avoiding criminal assault and pleading to a misdemeanor with no jail, but just 10 days of community service going to hurt his chances of getting a job as a lawyer elsewhere? He also has to go through some alcohol program (no details in the article). Maybe he can find some clients/and or employers in the alcohol program. He may also have contact with some EMS personnel in the alcohol program.
 

As Ms. Soler’s colleagues began to disperse, one suggested that Mr. Jaccarino should spend some time in their shoes, shouting: “He should do his community service on an ambulance.”[3]

 

Also see –

Plea Bargain Avoids Jail, Gets “Slap on Wrist”

and –

Assaults on EMS Providers Cry For Justice

and –

When is a Felony Not a Felony? for a bit more sarcasm than I provided.

Kelly makes the wrong argument. Drunk driving is already covered by specific laws that require intoxication.

What about assault laws that do not require intoxication? What if a drunken Assistant District Attorney Michael Jaccarino had attacked someone with a club, or with a knife, or with a gun? Would the prosecutor be claiming that it would have been difficult to prove that he meant to assault Ms. Soler?

Does possession of a weapon demonstrate intent?

Does access to a weapon demonstrate intent?

Does choking demonstrate less intent?
 

Mr. Jaccarino was so drunk, Ms. Walton told Judge Melissa A. Crane, that it would have been difficult to prove that he meant to assault Ms. Soler. She added that if Mr. Jaccarino’s “intoxication was of such an extent and nature to render him incapable of forming the particular criminal intent, then he would not be criminally responsible for committing this crime.”[3]

 

District Attorney Charles J. Hynes appears to be tough on assault only at press conferences.

District Attorney Charles J. Hynes did not hold a press conference this time.

–

Footnotes:

–

[1] Assaults Against EMT’s and Paramedics Initiative
Brooklyn District Attorney’s Web Page for October 2012.

–

[2] City emergency workers livid at wrist slap for drunken prosecutor who assaulted EMT
By Laura Italiano
Last Updated: 6:14 AM, February 14, 2013
Posted: 2:53 AM, February 14, 2013
NY Post
Article

–

[3] Prosecutor Who Assaulted Ambulance Worker Avoids Jail Sentence
By Colin Moynihan
Published: February 13, 2013
NY Times
Article

.

Filed Under: Heresy, Legal Medicine

Firefighters Fuming Over Ruling in Paramedic Attack

Fri, 21 Dec 2012 10:00:36 -0500 by
 
Even when the law is strict, the judge may be unreasonably lenient.

Was the judge unreasonable? According to the information in this article, which may not be entirely accurate, yes.
 

 

The Chicago Firefighters Union is expressing outrage that a man convicted of attacking two fire paramedics walked out of court this week with a virtual slap on the wrist.

Jonathan Soto of Bartlett was charged with four counts of aggravated battery for the 2011 incident, but a Cook County judge convicted him on only a lesser misdemeanor charge.[1]

 

What did Mr. Soto do?
 

“He was choking me,” she said. “He had me pinned in the back of the ambulance on our bench seat, choking me. … I couldn’t free his hands from me, so I was able to get my knees in between us and kick him off of me.”[1]

 

Should the use of deadly force be taken lightly?
 

he was charged with aggravated battery, a class 3 felony punishable by up to five years in prison.[1]

 

Apparently, the police did take this seriously.
 

In a brief bench trial this week, Judge James Linn listened to testimony but found Soto guilty of only a lesser reckless conduct charge. He sentenced him to a year of supervision, and 20 days of community service.[1]

 

Supervision by the court?

What does that mean?

Does he have to ask for permission to choke a paramedic next time?

How would the judge handle sentencing if Mr. Soto had been choking a judge?

Supervision and community service or a felony conviction with serious prison time to match the seriousness of the act?

–

Footnotes:

–

[1] Firefighters Fuming Over Ruling in Paramedic Attack
Firefighter paramedics Margaret Heckman and Michelle Martinez were attacked by a man in May 2011
By Phil Rogers
Thursday, Dec 20, 2012
Updated 7:02 PM CST
5 NBC Chicago
Article

.

Filed Under: Heresy, Legal Medicine

Advertising unapproved uses of drugs is free speech, which is what the FDA has been trying to say

Wed, 05 Dec 2012 10:00:15 -0500 by
 

Off-label drug use is very common.

This is a ruling a ruling that only affects New York, Connecticut, and Vermont,[1] but may be reviewed by the full Second Circuit Court and by the Supreme Court. That won’t stop it from having an effect nationally. What power does the FDA (Food and Drug Administration) have to regulate what drug representatives may say about uses of drugs that are not FDA approved uses, but are completely legal uses for the doctors they are talking to?

The FDA rules do prohibit drug representatives from discussing uses of drugs that are not FDA approved.

The FDA rules do not doctors from prescribing drugs for uses that are not FDA approved.

This is off-label drug use.

The NAEMSP (National Association of EMS Physicians) has a position paper on off-label drug use.
 

If EMS medical directors use a product for an indication not in the approved or cleared labeling, they have the responsibility to be well informed about the product, to base its use on firm scientific rationale and on sound medical evidence, and to maintain awareness of the product’s use and effects[2]

 

This should be true for any medical treatment.

The most important part of the article on the ruling is this quote –
 

Gerald Masoudi, a former chief counsel of the F.D.A., said the ruling made a distinction between truthful discussion of off-label uses of drugs, many of which are considered legitimate by the medical community, and those that are misleading or false. He noted that “anyone on the planet” could discuss off-label uses of drugs, except for pharmaceutical companies.

“It’s very significant,” he said, “because it’s going to make F.D.A., in its promotion cases, focus on the kinds of speech that are more likely to harm consumers, such as false or misleading marketing versus something that is not approved.”[3]

 

Will that be the case?

That is the way it should work, but the politics of regulation may not be ready for such a reasonable approach.

The FDA should focus on whether the communication is honest and complete, rather than whether taboo topics are mentioned.

 

Then there are the several different flavors of off-label.

1. The label does not mention the particular use, or dose, or population as being approved. Intranasal and intraosseous medication administration are just some of the reasons that EMS drug use can be off-label drug use.

2. The label mentions the use, but points out problems with the use. Haloperidol given intravenously, or in larger doses, is an example.[4]

3. The label has a black box warning. Droperidol is an example.[5]

There are FDA approved drugs that have the same problems, but without the formal warnings. According to the small print of the FDA label, amiodarone has greater problems with QT prolongation and torsades than haloperidol or droperidol, but there is no warning.[6]

While amiodarone does not have any of these warnings, the documented rates of QT prolongation and torsades appear to be greater with amiodarone than with droperidol. Droperidol receives the kiss of death, while amiodarone receives recommendations from the AHA (American Heart Association).[7]

In what way does such an inconsistent approach benefit patients?

Off-label use has also led to many problems, but that is more than can be covered today.
 

Image credit.[8]
 

This decision has not yet been covered on The Volokh Conspiracy, which can be expected to provide excellent insight to the way the law works and what decisions mean for everyone else.

–

Footnotes:

–

[1] United States Court of Appeals
Wikipedia
Article

–

[2] Off-Label Use of Medical Products
NAEMSP Position Statement
Position Statement in PDF format at NAEMSP.org

–

[3] Ruling Is Victory for Drug Companies in Promoting Medicine for Other Uses
By Katie Thomas
Published: December 3, 2012
NY Times
Article

–

[4] Information for Healthcare Professionals: Haloperidol (marketed as Haldol, Haldol Decanoate and Haldol Lactate)
Postmarket Drug Safety Information for Patients and Providers
Page Last Updated: 09/29/2009
FDA letter

There is a black box warning for haloperidol, but there is no mention of this in the black box warning. This is mentioned elsewhere in all capital letters.

FDA ALERT [9/2007]: This Alert highlights revisions to the labeling for haloperidol (marketed as Haldol, Haldol Decanoate and Haldol Lactate). The updated labeling includes WARNINGS stating that Torsades de Pointes and QT prolongation have been observed in patients receiving haloperidol, especially when the drug is administered intravenously or in higher doses than recommended. Haloperidol is not approved for intravenous use.

–

[5] DROPERIDOL injection, solution
[Hospira, Inc.]
DailyMed
FDA label

Here is the first paragraph of the black box warning on the label.

WARNING
Cases of QT prolongation and/or torsade de pointes have been reported in patients receiving droperidol at doses at or below recommended doses. Some cases have occurred in patients with no known risk factors for QT prolongation and some cases have been fatal.

–

[6] AMIODARONE HYDROCHLORIDE injection, solution
[Hospira, Inc.]
DailyMed
FDA label

–

[7] Where are the Black Box Warnings on These Drugs – II
Rogue Medic
Sun, 11 Dec 2011
Article

–

[8] Boost for Off-Label Drug Use – FDA Would Let Firms Keep Doctors Informed On Unapproved Methods
By Anna Wilde Mathews and Avery Johnson
Wall Street Journal
Article

.

Filed Under: Critical Judgment, FDA, Heresy, Legal Medicine, Pharmacology

Improving the Quality of Medical Care and Other Topics on the EMS Garage from the 2012 EMS Expo

Fri, 23 Nov 2012 08:00:07 -0500 by
 

 
Chris Montera (the man behind the EMS Garage), Pat Songer (Director of EMS at Humboldt General Hospital, Winnemucca, NV), Matt Womble (Principal at Womble Consulting), and I were on a video podcast from the 2012 EMS Expo in New Orleans.

You can watch the video podcast at the ProMed Network page here.

There may have been some sort of plan for an initial topic, but as Chris mentions, the EMS Garage wanders.

We started by discussing Burning Man.[1] I am the only one who has not been there.

We switched to patient satisfaction scores.[2]

But the most important topic was improving the quality of patient care by being able to discuss errors without fear of punishment.[3]

 

Image credit.
 

Some people keep trying to get rules that have been set up to prevent lawyers from being able to troll for torts by having access to this privileged information.

Would lawyers feel the same way about having to divulge their conversations with clients, rather than have it considered privileged information?

Some people just do not understand that the satisfaction of finding out some bit of information now comes at the price of having all similar information kept secret in the future.

Some people just do not understand that the satisfaction of finding out some bit of information now comes at the price of not protecting patients from similar errors in the future.
 

Discouraging isolated episodes of negligent care without lifting institutional performance more broadly would surely be a Pyrrhic victory for tort law’s deterrent effect.[4]

 

The tort system does not lead to a decrease in errors, or in improved protection for patients, but working to identify and eliminate errors does provide the opportunity to protect patients. As Matt Womble keeps stating – We can’t expect other people to do our job for us. We need to educate people about what we do and how to do it better.

We need to fix our own quality problems, because the lawyers certainly are not improving the quality of medicine. If we won’t fix our quality problems, why should we expect non-medical people to fix our problems?

We feel that we have to do something, and the tort system is already in place, but where is the evidence that the tort system improves outcomes for patients.
 

You can watch the video podcast at the ProMed Network page here.

–

Footnotes:

–

[1] Burning Man
Wikipedia
Article

–

[2] EMS Garage on Press Ganey – Should We Reward High Scores
Wed, 27 Apr 2011
Rogue Medic
Article

–

[3] What if confidential information, provided to protect patients, were no longer confidential?
Sat, 30 Jun 2012
Rogue Medic
Article

–

[4] Relationship between quality of care and negligence litigation in nursing homes.
Studdert DM, Spittal MJ, Mello MM, O’Malley AJ, Stevenson DG.
N Engl J Med. 2011 Mar 31;364(13):1243-50.
PMID: 21449787 [PubMed – indexed for MEDLINE]

Free Full Text from New England Journal of Medicine

Tort theory suggests that litigation induces defendants to be more careful and warns others to take precautions.28 But to be effective, this deterrent function logically requires a degree of precision.

CONCLUSIONS
The best-performing nursing homes are sued only marginally less than the worst-performing ones. Such weak discrimination may subvert the capacity of litigation to provide incentives to deliver safer care.

.

Filed Under: EMS Expo, Heresy, Legal Medicine, Risk Management

Irony is the Word of the Day at Brooklyn DA’s Office – A Lesson From Michael Jaccarino

Sun, 11 Nov 2012 11:15:41 -0500 by
 
Sylvia Browne never predicted this, but this would require a valid ability to predict the future.[1]

Less than a month after I wrote about the King’s County DA’s Office announcing an Assaults Against EMT’s and Paramedics Initiative,[2] one of their prosecutors has been arrested for assaulting an EMT in the back of an ambulance.

 

Kings County District Attorney Charles J. Hynes joined Brooklyn officials including New York Fire Department Commissioner Sal Cassano; Israel Miranda, President of the Uniformed EMT’s, Paramedics and Fire Inspectors Local 2507 FDNY; Senator Martin Golden; Senator Eric Adams; Assemblyman Peter Abbate Jr.; and Assemblyman Felix Ortiz as they called for legislation which would increase penalties for assaults against EMT’s and paramedics. The initiative would also assign an Assistant District Attorney in the Investigations Bureau to review and prosecute these cases.[3]

 

If he is serious about the initiative, Kings County District Attorney Charles J. Hynes will probably make an example out of Michael Jaccarino.
 

A prosecutor in the Brooklyn district attorney’s office was arrested early Saturday and charged with assaulting an emergency worker in an ambulance that was bringing him to a Manhattan hospital, the authorities said.[4]

 

Brooklyn is King’s County, one of the five counties (boroughs) that are in New York City.
 

Mr. Jaccarino, 30, was charged with assault, criminal obstruction of breathing, menacing and harassment.[4]

 

criminal obstruction of breathing?

Maybe the DA’s office does not use the term choking so as not to offend any of the local sports teams.

I wasn’t choking her, I was gently massaging her windpipe, so that she would understand the logic of my argument.

I would be interesting in finding out what they consider non-criminal obstruction of breathing. If crimes require intent, what kind of unintentional obstruction of breathing is suggested?
 

“He’s been suspended pending the outcome of the investigation,” Mr. Schmetterer (Jerry Schmetterer, the chief spokesman for the Brooklyn district attorney, Charles J. Hynes) added.
[4]

 

How will the prosecution of Michael Jaccarino progress?

Quietly?

–

Footnotes:

–

[1] Sylvia Browne
Wikipedia
Article

In 1992, Browne was convicted of investment fraud and grand theft.[3] Her claims and predictions have caused numerous controversies and reports of her failed predictions have appeared in several newspapers.[4][5][6] Critics such as James Randi, with whom she has had a long running feud, say that she is a cold reader whose readings are indistinguishable from those achieved by mentalists using cold and hot reading techniques. Recent press coverage has asserted that she is inaccurate overall.[7]

–

[2] Paramedics ask for stiffer penalties after dozens of assaults
Fri, 26 Oct 2012
Rogue Medic
Article

–

[3] Assaults Against EMT’s and Paramedics Initiative
Brooklyn District Attorney’s Web Page for October 2012.

–

[4] Brooklyn Prosecutor Arrested in Assault of Emergency Medical Technician
NY Times
By Colin Moynihan
November 10, 2012, 6:36 pm
Article

.

Filed Under: Heresy, Legal Medicine
« Previous Page
Next Page »